For laparoscopic surgery, pointed surgical instruments, called trocars, are used to provide access to body cavities by creating puncture openings through the abdominal wall. Laparoscopic surgery often requires trocar punctures measuring 10 mm in diameter or larger. These punctures can only adequately be closed using suture closure of the fascia, the thick fibrous layer of tissue which lies between the muscle and the peritoneum. If the fascia is not properly sutured, the peritoneum and bowel may begin to protrude through the fascial opening, a condition called postoperative incisional hernia.
The most common method for closing these puncture openings utilizes a curved suture needle. The skin, subcutaneous fat, and muscle are retracted away from the puncture opening and the fascia is identified. The curved needle and the attached suture are passed through the fascia on one side of the puncture opening, through the abdominal cavity, and back through the fascia on the opposite side of the puncture opening. The ends of the suture are subsequently pulled closed and tied to close the puncture opening.
While frequently successful, complications may arise from the use of this method. If the patient is obese, several inches of subcutaneous fat must be retracted away in order for the fascia to be isolated. The thick layer of fat causes the fascial tissue through which the needle is to be inserted to be recessed several inches from the exterior of the abdominal wall, making manipulation of the needle between the thick walls of fat and tissue difficult. Because the procedure involves passing the needle into the abdomen, poor control of the needle may result in puncture of the underlying bowel or inadvertent incorporation of the bowel into the fascial closure.
Two other devices have also been used for fascial closure. One, the REMA device, comprises a long member which is inserted into the puncture hole with its distal end positioned in the abdominal cavity. Once the distal end of the long member is inside the abdominal cavity, a pair of needle-carrying members are extended laterally from the distal end of the long member. The needle-carrying members hold two needles with their pointed needle tips directed towards the interior surface of the abdominal wall, such that the axes of the needles are parallel to the axis of the long member. Each needle carries one end of a single suture. The long member is then pulled outward of the puncture hole in a longitudinal direction, causing the tips of the suture-carrying needles to advance towards the skin surface of the abdominal wall. A needle-clamping device is advanced towards the suture-carrying needles, engages with the needles and removes them from the abdominal wall. The suture ends are removed from the needles and tied off, the needles are retracted by the needle-carrying member, and the apparatus is removed from the abdominal cavity via the puncture hole.
The suture tie applied by the REMA device passes through the entire abdominal wall, including the skin, fat, and muscle. Necrosis of the skin and muscle tissue may occur because of the strongly tensioned suture tie that is required to close the strong and fibrous fascial layer. Moreover, because the REMA needles pass outwardly through the skin from the abdominal cavity, the device exposes the surgeon to the risk of being injured by the blind passage of sharp needles through the abdominal wall.
Another method involves inserting a suture through fascial tissue using a needle, retrieving the suture from the needle inside the abdominal cavity using a grasper, withdrawing the needle and reinserting it at a second location, passing the suture from the grasper to the needle inside the abdominal cavity, and withdrawing the needle with the suture attached. While this method satisfactorily sutures the opening, transfer of the suture between the needle and the grasper requires visualization inside the abdominal cavity, and thereby requires an additional trocar opening for insertion of a laparoscope. An additional closure method is thus needed for closing the trocar puncture used for the laparoscope.